* 

U.s. SANITARY COMMISSION. 

0 . 


REPORT 


OP A 


COMMITTEE OF THE ASSOCIATE MEDICAL MEMBERS 
OF THE SANITARY COMMISSION 


ON THE SUBJECT OF 

THE TREATMENT 


FRACTURES IN MILITARY SURGERY. 


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p , i / 



PHILADELPHIA: 

J. B. LIPPIRCOTT & CO. 

1862 . 


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b^ 2] 

2 


The attention of the Sanitary Commission has been directed to the fact 
that most of our Army Surgeons, now in the field, are unavoidably de¬ 
prived of many facilities they have heretofore enjoyed for the consultation 
of standard medical authorities. It is obviously impossible to place within 
their reach anything that can be termed a medical library. The only 
remedy seems to be the preparation and distribution among the medical 
staff, of a series of brief essays or hand-books, embodying in a condensed 
form the conclusions of the highest medical authorities in regard to those 
medical and surgical questions which are likely to present themselves to 
surgeons in the field, on the largest scale, and which are, therefore, of 
chief practical importance. 

The Commission has assigned the duty of preparing papers on several 
subjects of this nature, to certain of its associate members, in our princi¬ 
pal cities, belonging to the medical profession, whose names are the best 
evidence of their fitness for their duty. 

The following paper on “The Treatment of Fractures in Military 
Surgery” belongs to this series, and is respectfully recommended by the 
Commission to the medical officers of our army now in the field. 

FRED. LAW OLMSTED, 

Washington, Dec. 6th, 1861. Secretary. 


ON THE TREATMENT 


A 


OF 


FRACTURES IN MILITARY SURGERY. 


In military practice, peculiar difficulties are apt to exist in the treat¬ 
ment of fractures; so that the surgeon is sometimes obliged to amputate 
limbs which he might in civil life hope to save. These difficulties arise 
either from the want of suitable or adequate apparatus, or from the un¬ 
favorable conditions of the case; as on the field of battle, on the march, 
or wherever the patient must be transported any distance before finding 
the rest and quiet so essential to his comfort or even safety. It has there¬ 
fore been thought by the Sanitary Commission that some hints upon this 
branch of surgery, and especially upon the expedients which may be 
resorted to in emergencies, might prove useful to those engaged in the army 
medical service. 


MATERIALS FOR SPLINTS, ETC. 

A supply of heavy pasteboard, or binder’s board, will be found of great 
value for making splints. It may be cut into strips eighteen inches long 
and six wide; there should also be a dozen or more pieces of twice this 
width, for making angular arm-splints. Paper of any kind, but the 
stouter the better, folded to give it sufficient firmness, may be substituted 
in many cases, when pasteboard cannot be had. Wide straps of thick 
leather, or even strips of the bark of certain trees, will often answer. 

The pasteboard, first softened in hot water, is moulded to the injured 
part, and confined in its place by means either of bandages or of adhesive 
plaster. Cold water will soften it, but not so well as hot; it may be bent 
without either, but is not then very manageable, and moreover is apt to 
break. 


( 3 ) 



Bandages ought never to be applied directly to a fractured limb at first, 
except in special cases, as for instance when the patella or the olecranon 
is the seat of injury. This rule is particularly imperative where the sur¬ 
geon is obliged to send the patient away from his immediate oversight, 
since irreparable mischief from constriction of the swollen limb may have 
ensued before it is examined by another medical officer. 

Splints should never be too small. If flat, they should be wider than 
the broken limb, so that a triangular space is necessarily left between the 
splint and the bandage on either side of the limb. In recent cases, where 
swelling is to be looked for, this is a matter of importance. Shaped splints 
should never surround the limb more than one-third, and there should 
always be a layer of some yielding substance, such as cotton batting or 
folded flannel, tow, or bags stuffed with bran, chaff, sand, sawdust, dried 
leaves, or fine hay, between any splint and the skin. 

Splints should never be too short. The whole of the broken bone needs 
support, and in order to this the joints at either end must be secured as 
far as possible at perfect rest. Nothing is more essential to safety and 
comfort during transportation than attention to this point; and the only 
safe rule is to aim at supporting the entire limb. 

Wooden splints are somewhat less easily attainable in military than in 
civil practice. If flat, they may be made to fit better by conforming their 
outlines to those of the injured limb; it is sometimes well also to cut holes, 
with carefully rounded edges, for the reception of bony prominences, such 
as the condyles of the humerus. Tin splints are highly spoken of by some 
authors; the only disadvantage they have is that they cannot be so accu¬ 
rately adapted to the part as pasteboard, unless the sheets are selected 
especially on account of their thinness, and then they would be apt not to 
be firm enough. 

An excellent plan for putting up fractures of the extremities, in an 
emergency, may almost always be adopted; it is only strange that it is so 
little known. This is to take a bundle of straw, the stiffer the better, 
(wheat straw is the best,) and to enclose the limb in it, the component 
straws lying parallel to the axis of the limb. The latter and its envelope 
may then be bound round with wisps of straw, strings, bandages, or any 
convenient article, care being taken not to compress the seat of fracture 
too strongly. Greater firmness may be given by inserting two or more 
sticks among the straws at either side of the limb. Should swelling now 
occur, the dressing will yield, the straws being simply drawn out in the 
direction of their length. The state of the parts may be readily watched; 
haemorrhage will be at once manifest; and when the dressing is to be 
removed, we have only to loosen the circular bands. Extension and coun¬ 
ter-extension may be made in various ways, upon a limb thus done up. 
When suitable straw is not to be had, hay, the stems of bushes, corn-stalks 


5 


or leaves, cane-stalks, twigs, or small sticks may be substituted. Almost 
any fracture of tlie extremities can be thus arranged so as to be comfort¬ 
able, even if the patient has to be transported some distance. And in 
those rare cases in which the bones of the trunk are broken, either on the 
march or in the field, the whole body may be encased in the same way, a 
much larger bulk of straw being of course required. 

In some countries, the custom prevails of placing broken limbs in a 
mould of wet clay, which dries into a very solid case. This might be 
resorted to temporarily, in the absence of all other appliances, but has the 
disadvantages of weight and liability to crack. 

Wire has of late years been extensively employed for the construction 
of splints. It may be provided in the form of a fine net-work, in rolls, to 
be cut in the figure wanted for use; or coarse wire may be carried in coils, 
pieces being cut off and bent into shape when required. The latter is 
generally made into a frame, on the under side of which the limb is, as 
it were, suspended in the turns of a bandage. 

At a somewhat advanced stage of the treatment, the danger of swelling 
is past, and the patient is usually placed under more favorable circum¬ 
stances for the employment of the immovable apparatus, in some one of its 
forms. The best of these is perhaps the plaster of Paris splint or band¬ 
age; the splint being made by dipping coarse old washed muslin, pre¬ 
viously cut and folded to the proper shape, in plaster mixed with cold or 
hot water, and the bandage by rubbing in dry plaster into the meshes of 
an ordinary roller, which is moistened as it is applied. None but the best 
finely ground plaster should be used; its setting or hardening is quickened 
by the addition of a little salt, delayed by that of a few drops of mucilage. 
Some surgeons apply the plaster to the naked skin, previously greased. 
Another form of moulded splint may be made by folding old flannel, and 
saturating the outer thickness of it with shellac or varnish of some kind 
Felt is used by many surgeons in preference to any other material for 
making splints. Starched and dextrinated bandages have fallen somewhat 
into disuse of late years, the slowness with which they harden rendering 
them particularly unsuitable for employment in military practice. 

We decidedly recommend immediate reduction whenever it is at all 
practicable. It is not true that the parts remain wholly inactive for eight 
or ten days, for swelling occurs by effusion of lymph and congestion, and 
the muscles shorten; so that it may be extremely difficult at the end of 
that time to bring the fragments into place. 

In all cases of doubtful diagnosis, as when the injury is near the hip- 
joint, it is better to etherize the patient thoroughly, so as to relax the 
muscles, and render the examination of the part not only less painful, but 
more satisfactory to the surgeon. , 




6 


COMPOUND FRACTURES. 

The compound fractures met with by the army surgeon are in a very 
large majority of cases the result of gunshot; and the improvements in 
modern fire-arms have given these injuries a much more uniformly serious 
character than they formerly had. It is very seldom the case now that a 
ball touches a bone without shattering it; and this does not involve the 
necessity of a large wound of either the skin or the periosteum,—a fact 
which modifies not only the diagnosis, but the course and prognosis of 
gunshot fractures. 

When amputation is not at once called for, (a matter elsewhere dis¬ 
cussed—see Documents F and G,) the surgeon’s great object should be to 
change the compound fracture into a simple one. 

Hence the wound must be cleansed of all dirt, foreign bodies, balls, bits 
of clothing, or loose splinters of bone. With regard to these latter, all the 
best authorities, Malgaigne, Baudens, Macleod, Bryant, Longmore, agree 
that they ought to be diligently sought for and removed. Dupuytren 
classified them into— 

1. Primary, completely detached by the injury itself. 

2. Secondary, so slightly retained by periosteum as to become loose 
when inflammation is set up. 

3. Tertiary, liable to subsequent necrosis. 

The latter, from their size, shape, or situation, may have to be left 
in place for a time; the two former should always be extracted as early as 
possible. The surgeon must use his best judgment in distinguishing be¬ 
tween the different forms of splinters. 

Haemorrhage should be completely checked, by the ligation of the main 
artery of the limb, if it cannot be done otherwise. 

Resection of the ends of the fragments is sometimes necessary, when 
they project through the wound, or have forced their way through the 
skin, and cannot be reduced. The sawing should be done obliquely, and 
in such a way as to favor the accurate fitting together of the cut surfaces. 
Much trouble from spasm and tension of the muscles is thus obviated, 
especially when the patient has to undergo transportation. 

Sutures can only be used in very rare cases, when the wound is a large 
and clean one; and they should always be amply supported, unless the 
patient can be kept under the surgeon’s eye, by adhesive strips. 

Bandages ought never to be applied to compound fractures on the field; 
the best plan is to put the part up in a bundle of straw, with or without 
extension, or to fasten it to a splint of some kind with broad adhesive 
strips. In the later stages of the treatment, when there is less hurry, and 
more conveniences are at hand, the bandage of Scultetus may often be 


7 


usefully employed; it consists of strips of muslin, whose length is about 
one-third more than the circumference of the limb, laid so as to overlap 
one another by about one-third, and then brought up so as to surround the 
part. The chief use of this is to make slight compression, and to retain 
dressings; it has the advantage that any of its constituent strips, when 
soiled, may be easily withdrawn, a fresh strip being pinned to one end of 
the soiled one so as to be put in place at once without disturbing the 
limb. 

j Extension is always a matter of more or less importance, and sometimes 
suffices of itself to keep a broken limb in comfort. It is easily made with 
adhesive plaster, a handkerchief, a wisp of straw, or a piece of bandage. 
Sometimes it is well to recollect that the patient’s boot or shoe need not 
of necessity be taken off in order to apply the extending band. Counter¬ 
extension may be made by handkerchiefs or any other convenient means. 
When the patient must undergo transportation, it is almost always better 
to fasten the extending and counter-extending bands to fixed points in the 
litter or bed, or on the floor of the wagon; pegs being driven for this 
purpose if necessary. 

There is, however, one case in which continued extension may do harm, 
if made too powerfully; it is when a considerable loss of the substance of 
the bone has occurred, so that the fragments need rather to be held 
together than to be drawn apart. 

The dressings most suitable in these cases are composed merely of lint 
or soft old rags wet with cold water, lightly confined in place. If the sur¬ 
geon has to send the patient away from his constant oversight, warm-water 
dressings, covered with oiled silk, or some other impervious material, are 
likely to be comfortable for a much longer time than cold, which require 
moistening as evaporation takes place. 

Ice or ice-cold water has been highly spoken of, particularly by Prof. 
Esmarch, of Kiel, as a local application in compound fractures as well as 
in other injuries. A trial of it is recommended. 

When suppuration is set up, the surgeon must provide some means of 
soaking up the discharge—and there is nothing better for this purpose 
than ordinary bran. It was, indeed, proposed by Dr. J. R. Barton to 
dress compound fractures simply by embedding them and covering them 
over with bran. 

A very annoying and disgusting circumstance, which sometimes takes 
place in compound fractures, is the development of maggots in the wound. 
This can only be prevented by keeping the part covered so that flies 
cannot get at it to lay their eggs. The maggots can be destroyed by lye- 
washes, or by diluted solution of chlorinated soda. 


8 


SPECIAL FRACTURES. 

Fractures of the Lower Jaw. —These are best treated by means of the 

bandage described by Dr. Barton, and known 
by his name. (See cut.) Another and simpler 
plan is to slit up a bandage, 3 inches wide 
and a yard in length, from either end to 
within 3 inches of the centre; which being 
applied over the jaw, the two tails on either 
side are crossed over one another, and the 
corresponding ones tied at the top and back 
of the head respectively. A cap of paste¬ 
board, folded paper, or even plaster of Paris, 
should first be fitted to the chin. If time 
permit, the coaptation of the fragments may 
be further ensured by enclosing the teeth adjoining the injury in a loop 
of fine wire, tightened by twisting its free ends together. The extraction 
of a tooth is seldom if ever necessary to enable the patient to take food. 

Fractures of the Clavicle. —In these we must often be content with 
simply suspending the arm in a sling, made or folded into a triangular 
shape, the apex being pinned or sewed up so as to bring the elbow as far 
as possible across the front of the chest. The best bandage is Velpeau’s, 
particularly when the patient has to be transported; it is so little known 
in this country that a description of it may be useful. The hand of the 
injured side being brought up so as to rest upon the sound shoulder, a 
roller 2J inches in width is applied, beginning in the sound axilla, passing 
across the back to the injured shoulder, down in front of the arm, under 
the elbow, up behind, and over the shoulder, and down across the front of 
the chest to the original point of starting. This having been several times 
repeated, turns of the bandage are made horizontally around the body and 
the arm of the injured side, from below upward, until only the hand and 
the tip of the shoulder are left uncovered. The arm is thus bound to the 
trunk, and the whole is secured by inserting pins wherever the turns of 
the bandage cross one another. 

Whenever it is practicable to place the patient permanently on his back, 
the deformity in fractures of the collar-bone will be found much lessened, 
or almost entirely corrected. 

Fractures of the Bibs and Sternum. —These call simply for pressure 
on the walls of the chest; which may be made either by applying broad 
strips of adhesive plaster, first stretched , covering in the point of injury 




9 


and several inches on every side of it, by surrounding the chest with firm 
turns of a broad bandage, or by any other constricting means which may 
be at hand. Compresses judiciously arranged are sometimes of great use 
in bringing the pressure to bear upon the exact points needing it. 

Fractures of the Humerus must be differently treated according to the 
point at which the bone may have been broken. But it must always be 
remembered that from the form of the limb the leverage on the fragments 
is very great, so that the whole member must be well supported. Short¬ 
ening must be carefully obviated when the line of division is oblique. 

Angular splints of w T ood or pasteboard answer the end best; if these 
cannot be obtained, a mould of clay or of plaster of Paris may be used, or 
the straw previously described, as a temporary resource. 

In making an angular splint, the part intended for the upper arm should 
be left at least 10 or 12 inches long, so as to reach completely up into the 
axilla. When the fracture is very high up, the splint being cut to fit the 
inside of the arm and forearm, the elbow being at a right angle, a paste¬ 
board cap should be adapted to the shoulder and upper half of the arm ; 
and then, the limb being bound to the splint, the cap should be fixed in 
place by figure-of-8 turns around it, the body, and the axilla. The object 
of this is to confine the scapula, and through it the upper fragment. When 
the shaft is broken at any point in its length, either an inside or an anterior 
angular splint may be used, one, two or three short pieces being placed on 
the arm so as to confine it still more closely. If the seat of fracture is 
low down, close to the condyles, or involving one or both of them, any 
lateral splint is apt to press the lower fragment out of place; and hence 
an anterior angular splint is preferred by many surgeons, its angle fitting 
across the bend of the elbow, and the forearm being in complete supina¬ 
tion. But this posture is an unnatural one, and cannot be comfortably 
endured for any length of time. Hence it is better to combine the inside 
and anterior angular splints, by tacking a piece of pasteboard of the proper 
size and shape to the upper 
or arm portion of an ordin¬ 
ary wooden inside angular 
splint. Or, cutting out the 
whole from one piece of 
pasteboard, we may follow 
the outline of the inside an¬ 
gular splint, but make the 
upper portion, above the 
angle, a little more than 
twice as wide as usual; and then, cutting a slit half way across it, contin¬ 
uous with the upper edge of the forearm part, we have a portion which 










10 


may be bent over so as to fit the front of the arm. (See cut.) All these 
inside angular splints should have the part corresponding to the hand cut 
at an obtuse angle with that for the forearm, so that the hand may be 
inclined toward its ulnar border; this will add greatly to the patient’s 
comfort. 

It is easy to see how the same purpose could be answered with a piece 
of stout wire, bent so as to form a frame for the limb, well wrapped in 
bandage, and secured like any other splint. 

Extension and counter-extension, when a strong tendency to shortening 
exists, may be best made by means of a separate splint, applied first of 
all, and reaching along the back of the arm from above the shoulder to 
below the elbow, bands of adhesive plaster being passed beneath the axilla 
to its upper end, and over the bend of the elbow to its lower. 

Fractures of the Forearm .—The bones of the forearm are exactly on a 
plane with one another when the hand is in the semiprone posture, and at 
the same time none of the muscles are put upon the stretch; this is there¬ 
fore the proper position to be given to the hand in all cases of fracture of 
the upper extremity. It is most effectually secured by means of an inside 
angular splint, similar to that for fracture of the humerus; the upper or 
arm part of such a splint not only preventing rotation of the hand, but 
serving to increase the steadiness of the broken bones. Narrow com¬ 
presses, so arranged as to preserve the interosseous space, ought always to 
be employed. The forearm part of this splint may be made on the prin¬ 
ciple of that known by the name of its inventor, Dr. Bond; its edges 
being cut to correspond with the outline of the forearm, and a block, a 
wad of paper, a mass of clay, plaster or wax, or a pad of tow, arranged 

so as to be grasped in the palm of 
the hand. If this block or pad is too 
large, it will simply bend the wrist back¬ 
ward. The same purpose may be an¬ 
swered, if the splint is made of paste¬ 
board, by cutting it long enough to 
reach the ends of the fingers, softening its end in water, and then doubling 
or rolling it backward. (See cut.) 

Angular deformity is less likely to ensue in fractures of the ulna or of 
both bones near the middle, if a slip of leather or of pasteboard is tacked 
along the ulnar border of the splint, or by turning up this border if the 
splint is made of pasteboard. 

Fractures of the olecranon are even rarer in military than in civil sur¬ 
gery; they are best treated by means of an anterior pasteboard splint, 
bent very slightly, and adhesive plaster directly applied so as to keep the 
fragment as nearly in place as possible. 






11 


For fractures of the metacarpal bones or phalanges , a hand-splint should 
be used, with a block or pad as described above. In many cases, it is suf¬ 
ficient to close the hand over a ball of the proper size, securing it so by 
means of adhesive plaster. 

Fractures of the lower extremities are especially difficult of manage¬ 
ment, on account of the size and weight of the parts involved, and the 
consequent trouble in fixing the fragments so as to prevent their rubbing 
against one another or tearing the adjacent soft tissues. 

In the thigh , the bone being single and comparatively small, the muscles 
powerful, and the leverage on the lower fragment great, it is very gener¬ 
ally necessary to use some extending force from the outset. 

Sometimes, on the march or in the field, we must be content with the 
straw-splint described in Section I; but if possible, some form of exten¬ 
sion should be added to this. Thus a board of proper length may be 
placed along the outer side of the limb, and a handkerchief folded cravat- 
wise passed around the perineum and tied to its upper end, while the foot 
is secured below in like manner. The extend¬ 
ing band may in such a case be tied over the 
shoe or boot. Or the board may be placed 
along the inner side of the limb, its upper 
end carefully padded, bearing against the 
perineum. 

Another plan, when the patient is to be 
transported in a vehicle, is to drive pegs into 
the floor of it at points corresponding with 
the axillge, and others a few inches beyond 
the soles of the feet; these pegs being long 
and strong enough to serve as points of at¬ 
tachment, the upper ones for the shoulders, 
the lower ones for the feet, by means of wisps 
of straw, handkerchiefs, bandages, or adhesive 
strips. (See cut.) Other pegs may be driven 
so as to be conveniently grasped by the hands 
of the patient. Whatever material is used for 
him to lie on, should be laid as evenly as pos¬ 
sible; and the injured limb should be care¬ 
fully and firmly wrapped in its own bundle of 
straw. 

When time permits, and a few boards can 
be had, a very good plan is to have a box 
knocked together, consisting of a bottom and 
two sides. The outer side should be long enough to reach from 4 inches 



























12 


below the foot to the axilla, the inner one from the same point to the 
perineum ; the bottom, smoothly bevelled off above at its upper edge, 
should reach from the tuber ischii as far down as the other two. Counter¬ 
extension may be made from the perineum as in the ordinary Physick’s 
apparatus, extension by any convenient band fastened to a peg driven 
either between the two sides, which is best, or vertically into the bottom 
of the box at its lower end. Straw, hay, sand, bran, cotton, tow, or even 
leaves, may be used to embed the limb and prevent its contact with the 
wood. 

In hospital, as a matter of course, the treatment may be as a general 
rule carried on much as in civil practice. Desault’s apparatus, as modified 
by Physick, is widely and favorably known. Counter-extension may be 
made either with the stuffed tube of buckskin or muslin, the perineum 
being daily washed with whiskey, and carefully dried before the band is 
reapplied , or by means of adhesive plaster when an abundance of this 
material is at hand. 

With regard to the extension, this is best made with adhesive plaster, 
in the following way: A strip 2 inches wide, and twice as long as from 
the seat of fracture to 3 inches below the sole of the foot, is stretched as 
much as possible. A bit of thin wood, 2 inches square, is next fitted to 
the middle of its adhesive surface, and on either side of this a small slit 
is cut lengthwise in the plaster. Through these two slits a strip of band¬ 
age is passed, so that the bit of wood is between the tw T o strips. The ad¬ 
hesive band being now applied up along each side of the limb, and fixed 
by two or three transverse or circular strips of plaster, it will be found 
that strong extension may be made by pulling on the two ends of the 
bandage, and may be rendered permanent by tying them to the lower part 
of the outside splint. During the early stages of the treatment, while the 
muscles are apt to contract spasmodically, it is well to insert in some way 
a piece of elastic material, which will yield somewhat, resuming its tension 
the moment the spasm subsides. 

Some surgeons, among w r hom is Dr. Buck, of New York, discard the 
long splint for fractures of the thigh, making counter-extension from the 
head of the bed, and extension by a weight attached to the foot and hang¬ 
ing at the foot of the bed. From 15 to 30 pounds will be requisite for a 
man of average muscular development. 

Short splints should always be employed when the long splints are 
omitted. They may be confined in place by means of circular bands of 
adhesive plaster, or by the upper turns of a roller which begins at the 
toes. If the long splints of Physick are used, they should be just wide 
enough to prevent the circular strips of bandage from bearing upon the 
skin of the limb ; they should each be lined, if possible, with a piece of 
old blanket, folded in four or five thicknesses. When this cannot be had, 


13 


cotton, linen or tow may be substituted for it, or bran bags may be used. 
A splint-cloth is useless, the same purpose being much better served by 
giving each of the circular strips of bandage a turn around each splint, 
enclosing also the lining, which is thus kept in place. Some sort of old 
stuff, woollen if possible, should be folded so as to form a protection to the 
whole under surface of the limb. The circular strips of bandage will be 
sure to stretch somewhat during the first 24 or 48 hours ; after that they 
may be made more secure by tacking them to the edges of the splints. 

Various forms of inclined planes have been described for the treatment 
of fracture of the thigh. The single inclined plane may be very usefully 
employed, with careful watching by the surgeon; it is made by fastening 
a board, as long as from the tuber ischii to an inch or two beyond the heel, 
and inclined at such an angle as may be judged suitable to an upright 
board, so that the latter shall project about a foot above the upper end of 
the former. Holes are bored in this projecting part, through which the 
extending bands pass to be tied, and the injured limb lies upon the slope, 
the weight of the body making the counter-extension. 

The double inclined plane is well known; its most recent and approved 
form is that given to it by Dr. N. R. Smith, of Baltimore. 

Dr. Smith’s splint consists in a rectangular frame of stout iron wire, 
about 3 inches wide at one end, and 2 J or 2f at the other; it is intended 
to reach from a little above the spine of the ilium to a point just beyond 
the toes, and should, therefore, be about 3 feet 8 inches long for a man of 
ordinary stature. Cross-pieces of wire are firmly clinched to the side- 
pieces at intervals of about 8 inches. There are also two double hooks of 
wire, each of which is adapted to clip the side-wires firmly, and has a loop 
above like a figure of 8, forming an eye for the attachment of a suspend¬ 
ing cord. A small pulley and a tent-block are useful, but not indispensa¬ 
ble to the apparatus. When the splint is to be applied, it is bent so as to 
correspond with the front of the limb when the hip, knee, and ankle are 
somewhat flexed; it is then wrapped in the turns of a bandage, and the 
limb bound to its under surface. The double hooks are now made to catch 
the splint at about the middle of the thigh and leg, and a cord attached to 
both; to the middle of this cord is tied the end of another, rove through 
the tent-block and passing over the pulley, which is fastened to the ceiling. 
Extension is made in proportion to the degree of slant assumed by this 
latter cord when the limb is thus suspended; the weight of the body is the 
counter-extending force. If the extension is not made properly, or if the 
splint presses too much or too little above or below, the points of attach¬ 
ment of the suspending cord should be changed; and the efficiency of the 
apparatus may be enhanced by raising the foot of the bed with blocks. 

Sometimes, when the bone is broken obliquely and high up, it may be 
necessary to use the inclined plane in order to bring the lower fragment 


14 


into proper relation with the upper, tilted upward by the action of the 
psoas and iliacus muscles. 

At a late stage in the treatment, union having duly taken place, and the 
callus merely needing support, some form of the immovable apparatus may 
be found useful. 

Fractures of the 'patella occur very rarely in army practice. When 
longitudinal, the only treatment they need is confinement of the limb and 
the subduing of inflammation. When transverse or oblique, it is necessary 
to fix the fragments, which may be done with strips of adhesive piaster 
applied above and below, a splint being placed behind the knee to prevent 
anything like flexion. Another plan, described by Dr. Sanborn, is to 
apply a roller from the toes to the trunk; before covering the knee with 
this bandage, a strip of adhesive plaster is laid lengthwise down the front 
of the lower part of the thigh and upper part of the leg, and fastened by 
turns of the bandage or by other strips, its middle part being, however, 
left uncovered. A hard compress is now placed Under this loop of ad¬ 
hesive plaster, above the upper fragment, and by pinching up the loop and 
twisting it with a piece of stick, the fragments will be pushed together. 

Fractures of the bones of the leg are extremely troublesome when they 
occur on the march. The same means may be used in these cases as when 
the thigh is the seat of injury,—straw-splints, temporary extension, a 
fracture-box, as circumstances may allow. Support should be given to the 
whole limb, from heel to hip, and the foot should be carefully secured from 
falling either inward or outward. 



The ordinary fracture-box, having a bottom, two sides, (fastened to the 
bottom by hinges of leather or iron, if possible,) and an end, the latter 
projecting up high enough to keep the bedclothes from weighing on the 
toes, may be stuffed with straw, or a pillow laid lengthwise in it, and 
serves as well or better than any other arrangement for the transportation 
of the patient. (See cut.) Extension and counter-extension can be readily 
made in such a box, in a manner which will suggest itself, when shorten¬ 
ing is present; adhesive plaster is the best material for the purpose. 

Wire splints may be adapted to the leg, as to the thigh; and any form 




















15 


of apparatus that is used will be made more tolerable by tbe suspension of 
tbe entire limb. It is better in these cases, in fitting tbe wire splint, 
to make tbe angle at the knee more obtuse than for a fracture of the thigh, 
and always to hang the limb in such a way that the broken bones may be 
horizontal. 

Should lateral angular deformity occur after fracture of the leg, it 
must be corrected by a careful adaptation of Dupuytren’s plan, by binding 
the limb to a lateral splint, with a wedge-shaped compress arranged so 
as to bear against the projecting angle. 

When, at an advanced stage of the treatment of fractures of the leg, 
pasteboard splints are used, they should always be applied to the sides of 
the limb; never to its posterior surface. 

Fractures of the tarsal and metatarsal bones , as seen in military prac¬ 
tice, are very apt not only to be compound, but to require amputation. 
In favorable cases, inflammation being subdued, a pasteboard splint should 
be accurately fitted to the front of the leg and back of the foot. When 
a fracture-box, like that recommended for the leg, can be had, it will 
ensure greater comfort to the patient, especially if he has to be moved 
any distance. 

JOHN H. PACKARD, Chairman. 

GEORGE W. NORRIS. 

GURDON BUCK. 

W. H. VAN BUREN. 

WM. A. HAMMOND. 

EDW. HARTSHORNE. 

























SANITARY COMMISSION. 










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